Computerized provider order entry (CPOE), clinical decision support (CDS), and other technologies can reduce prescribing errors, but their initial implementation may present new errors. This study reports prescribing errors before and after transition to digital hospital records. Results show significant decreases in prescribing errors after transition, but also identified new problems, such as alert fatigue, that needed additional attention to remediate.

Illegible prescriptions can cause pharmacists to dispense incorrect medications resulting in patient harm. This review identified 15 studies on illegible prescriptions. Most of the studies were more than 10 years old and the authors acknowledge the advent of computerized provider order entry (CPOE) has reduced incidence of illegible prescriptions. However, CPOE relies on highly functional information technology systems which may be cost-prohibitive for some countries.

This article describes results from the 2019 American Society of Health-System Pharmacists national survey regarding inpatient pharmacy practice. The authors note the increasing responsibilities placed on pharmacists and their role in addressing the opioid crisis, adopting intravenous workflow technologies, and leveraging clinical decision support tools to improve medication administration safety.

This observational study compared error detection rates for medication transcription errors between a hospital's formal reporting system and a passive error identification mechanism embedded in ordering software. As with prior studies of incident reporting systems, the formal reporting mechanism identified fewer errors than electronic surveillance, emphasizing the need to build error detection into technology platforms.

In this study, a hospital policy that allowed registered dieticians to directly enter physician cosigned diet orders for patients significantly decreased nutrition-related error rates and time delays.

Medication reconciliation revealed a high rate of prescribing and transcribing errors in the discharge medications of elderly patients at a Swedish hospital.

This study, one of the first to analyze prescribing errors in community primary care practices, found a remarkably high rate of errors. Nearly one in four prescriptions contained at least one error in dosing, frequency, or patient instructions, and a startling proportion of prescriptions had illegibility errors as well. Computerized provider order entry (CPOE) could have prevented a large proportion of these errors, and recent studies have shown that CPOE can decrease prescribing errors in community-based office practices. A Patient Safety Primer discusses outpatient medication prescribing errors and other pressing safety issues in outpatient practice.

Warfarin and other anticoagulant medications place patients, especially elderly ones, at high risk of adverse drug events (ADEs) due to their narrow therapeutic window. This retrospective analysis of anticoagulant-related ADEs at an academic medical center identified the underlying cause of these events and found evidence that a large proportion should be preventable. More than two-thirds of anticoagulant-related ADEs were attributable to medication errors, usually at the medication administration stage. A large proportion of the errors were ascribed to incorrect transcription of orders. The persistent incidence of transcription errors in this study is especially surprising given that the hospital in question already had a computerized provider order entry (CPOE) system. Fully electronic closed-loop medication systems, which integrate CPOE, barcoding, and electronic medication administration records, hold promise as a means of reducing both transcribing and administration errors.

Illegible handwriting has been cited as a major factor in several high-profile medication prescribing errors. This Swiss study found that the majority of handwritten prescriptions were considered "bad or unreadable," and more than half of the medication errors in this study were ascribed to transcribing errors attributable to poor handwriting.

Information technology solutions have proven effective at reducing some types of medication errors. For example, computerized provider order entry (CPOE) can reduce errors at the prescribing and transcription stages. Barcoding of medications has been advocated as a means of reducing medication administration errors; although some studies have found success, others have noted unintended consequences. This study tested a closed-loop system that combined CPOE, barcoding, and an electronic medication administration record in an academic medical center and found that the system significantly reduced administration errors as well as potential adverse drug events. The authors note that significant changes in workflow were necessary to achieve these results and caution that successful use of this technology requires considerable attention to development and implementation.

This monthly column highlights an initiative to introduce safer device connectors to prevent spinal and epidural medications from being delivered intravenously, discusses the value of independent double-checks, and shares thoughts on the 35th anniversary of this column.

This monthly article discusses incidents involving dosing errors and describes strategies to promote the safe use of oral syringes.